Fodmap Frequency

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MonthDayYearHourMinutesAM/PM Option

Full Name

First NameLast Name

Birth Date

MonthDayYear

How often do you eat the following foods (lactose)

Rows	almost never	sometimes	often	most of the time
Evaporated milk
Yogurt with added whey or whey concentrate, plain or sweetened with sugar only
Fluid milk
Buttermilk
Eggnog
Milkshake
Ice cream, frozen yogurt, ice milk, or soft-serve ice cream,
Regular yogurt
Greek yogurt
Cottage cheese
Kefir
Whey concentrate protein powder

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How often do you eat the following foods (Fructose)?

Rows	almost never	sometimes	often	most of the time
Beverages with crystalline fructose, such as Glaceau Vitamin Water
Emergen-C fizzy drink mix,
Agave syrup or nectar.
Barbecue sauce with HFCS
Pancake syrup (with HFCS)
Jam or jelly
Honey
Molasses
Gummy or chewable multivitamin supplements with fructose
Pears
Apples
Other fruit, whole
Fruit, cut up, fresh, canned or frozen
Fruit juice
Dried apples/pears
Fruit leathers
Candy
Chocolate
Sugar
Rum

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How often do you eat the following foods (Fructans)?

Rows	almost never	sometimes	often	most of the time
Fiber bars with inulin
High-fiber breakfast cereals with chicory root, inulin, wheat bran, rye, barley, 1 serving.
Rye bread or crackers
Barley
Bulgur wheat
Couscous
Gnocchi
Beet/beetroot
Broccoli
Brussels sprouts
Onions, raw or cooked
Artichokes or artichoke hearts,
Scallions (white part
Garlic
Shallots
Pasta, white or whole wheat
Radicchio
Cabbage
Yeast breads, English muffins, rolls tortillas, pitas or chapatis made with white, whole wheat, or multigrain flour.
Cookies,Cake or muffins made with white, whole wheat, or multigrain flour, ½ fast food serving
Donuts, Crackers or pretzels made with white, whole wheat, or multigrain flour
Pizza crust made with white, whole wheat, orr multigrain flour
Herbal tea or coffee replacement beverages with chicory, 8 fl. oz.
Dried raisins, cranberries, apricots, dates, fig

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How often do you eat the following foods (Polyols)?

Rows	almost never	sometimes	often	most of the time
Candy or Cough drops with maltitol,lactictol, isomalt,mannitol, sorbitol, xylitol, polydextrose, or hydrogenated starch hydrosylates
Liquid medication with maltitol, sorbitol, isomalt, lactitol, mannitol, xylitol, polydextrose, or
hydrogenated starch
hydrolysates
Low-carb bars
Prune juice
Prunes
Figs, dried
Blackberries
Mushrooms
raw
Cauliflower
Dates
Cherries

How often do you eat the following foods (Oxalates)?

How often do you experience any of the following symptoms? (HOX)

Rows	almost never	sometimes	often	most of the time
General – Burning, tingling or numb hands or feet
cold hands and/or feet
sensitive teeth and gums
burning lips
popping jaws
calcium deposits on cornea
Vomiting
Genital - Inflammation
Genital red or purple sores or bumps
Genital white patches or red spots
Genital stabbing or stinging
clitoral pain (or penile pain in men)
pain at vaginal opening
painful intercourse
internal pelvic pain or soreness,
rectal burning
vaginal pain
vaginal itching
vaginal spasm
vaginal redness
vaginal tears
vaginal burning discharge
bladder infections
concentrated or pungent urine
chronic interstitial cystitis
painful urination
urethra pain
Sensitive skin
pain when you tug on your hair

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Which of the following do you have any known or suspected sensitivities to.

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Sound Integrative Health